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LTH SAN JOAQUINnCOUERF LE RECORD NFORMAT ONAORMDEPARTMENT R CI V �IST D ❑ N1w EH Program at Existine Facility New EH Program and New Facility, AUG , Faciii ID D Pro ram Record IDIN() glyUDq ' ?Q Fac ilityAddress-135 R)01 rA-6 � ((� � }—�v'RWPME/VrAN y (Plea,6e check the appropriate description and specify size, number of units and pertinent information.) 1'04RTMEIVr FOOD PROGRAM(1600) / ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs I NO�❑ @Commissary RrDry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-Make Vehicle Type Color Registration# License# Sticker# Mobile Food Prep Unit-Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-Dates of operation from to 13 Ice Plant 13 Produce Stand ❑ Special Event—Dates of operation from to ❑ CFO ❑ A❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy 13 Grade B Dairy El Milk Dispenser-Number of Containers in Multi-Head Unit COPA. �- ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ Ca1ARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)------>-Tons Generated Per Year ❑ Tiered Permitting Facility---> ❑CA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) ❑Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑ Underground Storage Tank Program(UST)(2300)Use USTA and B forms ❑Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm---Maximum number of birds ❑ Kennel TATTOO BODY PIERCING.PERMANENT COSMETIC PROGRAM(4100) ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegistration# License# Capacity Vehicle# 11Pumper Yard 11Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) _ ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles R of units) ❑ Dumpsters>20 cu yd la of units) ❑ Fann/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 1:12-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 4602-003 Blue Application Form /'� EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON(!&,P f-0 b c ' -p CVDay Ph SIL-361 D5'19 Night Ph % k1D`30` - ©c CI PROGRAM ELEMENTFE .3�Q ❑ Surcharge FEE 13Other FEE INSPECTOR#�l%) 78S PERMITVA D S t0 $ 2-J ❑ Food Handler ❑ Cheok# AMOUNT PAID Date ;?Q INVOICE# 3 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date f 4&02-034 J ^ MASTERFILE RECORO INFORMATION PINK